This item is reserved for future use. Do not complete at this time.

Show the actual month, day, and year the current application was filed. Be aware that the only exception to this rule occurs when an earlier filing date is established based on a written or telephone request for benefits (see GN 00204.010) in which case, the earlier date should be shown. If there are two or more current applications, show the earliest filing date.

Enter the title, e.g., Mr., Mrs., Ms., name and mailing address of the claimant. If a proper applicant (see GN 00204.003) has filed on behalf of the claimant, enter the applicant's title and name followed by the "for" (or the appropriate legend), and then the claimant's title and name, and the applicant's mailing address. Enter names exactly as shown on the application. If two or more proper applicants have filed on behalf of the claimant, make sure the title, name and address entries for the applicant reflect the preferred payee.

In situations involving an application filed after the patient's death, show the applicant's title and name followed by “On behalf of (patient's title and name) Dec'd.”

Show the SSN of the ESRD claimant.

Show the telephone number at which the claimant or their payee can be reached.

Show the number holder for the SSN shown in item 8.

Show the claimant's relationship to the person shown in item 6.

Show the SSN on which entitlement is based if it is different from the one shown in item 4, (e.g., the claimant's Medicare entitlement is based on Federal employment or the claimant is already entitled to spouse's or child's monthly Social Security benefits).

Show the established month, day, and year of birth, e.g., 3/17/68. If the date of birth has not been proven, use the date of birth by which the claimant is the oldest.

Check “A” or “B” to identify the prior claims action, if any. (SSI claims do not require an entry in this block.)

Whenever “A” or “B” is checked, complete “C” to identify the type of claim previously filed.

When both “A” and “B” are checked and/or more than one item in “C” is checked, give a brief explanation in item 15 in non-DOFA cases, and item 39 in DOFA cases (e.g., ESRD denied 1984, DIB denied 1994, 1998, Age 65 HI allowed 2003.)

Show all other types of title II claims on which the ESRD claimant is currently entitled and/or on which there is a claim pending.

Check “yes” if insured status is based on Railroad Service or if the claimant is also a railroad annuitant (see HI 00801.011).

Show the SSA field office code.

Show the SSA field office address.

Complete only to notify ODO of a special situation e.g., a CDB reentitlement claim with reentitlement period dates, a DOFA exclusion case, a claim filed by or on behalf of a homeless individual, etc.

When concurrent claims are filed, show the current status of the alternate claim(s): “DWB claim on SSN       pending in FO” or “DWB claim on SSN       forwarded (date first claims material was forwarded to the DDS).”

Show the FO's administrative telephone number. If two telephone numbers can be used, show both.

Complete this block for initial non-DOFA claims.

Complete this block for initial non-DOFA claims. Show the date the FO transmits the SSA-892-U2 to ODO.

Check the appropriate box for type of claim or action.

1. a. 

   Check “A” (Initial) if:

   • •

     it is an initial ESRD Medicare claim (allowance or denial), or

   • •

     it is a new ESRD Medicare claim after a prior period of coverage terminated (see d. below).

2. b. 

   Check “B” (Recon) for a reconsideration request of an initial determination.

3. c. 

   Check “C” (Continuing) if the action is based on an alert.

4. d. 

   Check “D” (Other) if:

   • •

     the action is based on an appeal higher than a reconsideration, or

   • •

     the action is a reopening at any level, or

   • •

     the action is a subsequent period of entitlement processed at the same time as cessation; or

   • •

     the action is taken to revise a prior determination, to establish either an earlier date of entitlement, to affirm a prior determination, etc.

If “D” is checked, write the type of action to the right of block D (e.g., Affirmation, Reversal, etc.). Show more than one type of action, (e.g., an ALJ Reversal) if necessary.

Check more than one block in item 19 if necessary, e.g., if bullet 3 above applies, check blocks A. and D. Also, specify “term/ent. same month.”

Complete this box for all allowances for which entitlement is based on dialysis except continuing entitlement cases. In a no waiting period case, show the dates that would have applied if a qualifying period had been required. Show date as MM/DD/YYYY.

Complete this box for all allowances for which entitlement is based on dialysis and there was a prior period of HI entitlement. Show date as MM/DD/YYYY.

Check all boxes that apply:

• •

  Check “A” for allowances and continuation actions. See item 49 of form CMS-2728-U3 for the physician’s signature attesting ESRD

• •

  Check “B” if the beginning date of entitlement is based on dialysis or if the person began a regular course of dialysis after a transplant (continuing entitlement). Obtain this information from items 23 and 34 of the CMS-2728-U3.

• •

  Check “C” if the claimant had a transplant or transplant surgery and it is a factor of entitlement or (for continuing determinations) potential termination. Obtain this information from Section C of the CMS-2728-U3.

Check the appropriate box for initial claims.

Complete this item if the qualifying period is being waived due to self-dialysis training (Check “A”) or early transplant entitlement is established (Check “B”).

If the claimant had dialysis, complete this item in accordance with the information on the form CMS-2728-U3. If item 22B or 23A is marked, complete this item as follows:

Show the hospitalization date in “A” when early transplant entitlement applies. Make sure the month shown is earlier than the month shown in item 26B. If development is needed before a decision can be made, write “development taken” and process in accordance with HI 00801.233.I. If early transplant entitlement is not involved, leave blank.

Complete "B" for all cases in which the claimant received a transplant.

Complete in conjunction with item 26 and/or item 22C.

Check “A” (Yes) whenever the claimant is entitled to disability insurance benefits (DIB).

On the SSA-3293 or SSA-3601 routing forms enter in Remarks: “After all actions route to ODO Disability examiner-DIB beneficiary received kidney transplant.”

Check “B” (No) only if no previously adjudicated DIB allowance claim exists.

Check “A” (Yes) when self-care dialysis information is indicated in item 25C.

If “B” (No) is applicable, specify reason in item 39, e.g., training ended before completed for reasons other than death.”

Check “A” (Yes) if State buy-in is effective any month from the month of entitlement through the month of adjudication.

Check “B” (No) if State buy-in does not apply. If State buy-in is being developed, check “B”. However, document the folder that State buy-in is being developed.

(This item is used only for postadjudicative actions.)

(This item is used only for postadjudicative actions.)

Check “A” (Yes) if entitlement to R-SMI is established later than the R-HI entitlement date in accordance with the equitable relief procedures. If appropriate, also complete item 32C.

Check “B” (No) if the entitlement dates for R-HI and R-SMI are the same or the claimant refuses R-SMI coverage.

Check “C” (Developed) if the R-SMI premium arrearage is 6 months or more and there is no clear election of SMI or a SMI entitlement date by the claimant.

Refer to the equitable relief procedures in HI 00801.251B.

Remember that when dialysis is the basis for entitlement, the onset date will be the same as the entitlement date if the qualifying period is waived because of self-care dialysis (item 28A) or it is a no waiting period case (item 21); otherwise, the onset date (excluding retroactivity limitations and MSP considerations) will be the third month before the month of entitlement. When application retroactivity or MSP considerations restrict the R-HI date of entitlement, show the actual onset date as shown on the CMS-2728-U3.

Note that for transplant cases, the dates shown in A1. and C. will be the same except when application retroactivity or MSP considerations restrict the R-HI date of entitlement.

Complete for all disallowances. Check only the box that most realistically describes the situation. For example, if the claimant does not meet insured status and therefore no medical evidence (CMS-2728-U3) was developed, disallow the claim based on lack of insured status (item B.) rather than on no medical certification (item A.).

Specify type of development taken. If post-adjudicative development is not needed, show “None”.

Leave blank.

Complete in accordance with NL 00725.006 or NL 00725.008. If a dictated letter is needed, show “DL”.

If a listing code is needed, show the number; otherwise, leave blank.

Complete when:

• •

  situations described in item 15 above exist except that the case should be DOFA processed and/or

• •

  additional space is required for item 15 non-DOFA remarks.

Complete these items for all DOFA claims.